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New England Journal of Medicine on Circumcision


Medicine? ---no

Science? ----no

Politics?------yes

Did the New England Journal of Medicine Circumcise Medical Information?

To the Editor:

The New England Journal of Medicine(NEJM) printed a strongly pro-circumcision (anti-normal anatomy) editorial by Dr. Thomas Wiswell,1 but did not print the pro-normal anatomy alternative opinion (see Abstracts & Analysis). When misinformation in Wiswell's editorial was brought to the attention of the editor, there was no attempt to correct Wiswell's exaggerated benefit claims. Strangely enough, the NEJM printed a Sounding Board discussion of circumcision in 1990 examining the purported advantages and disadvantages of circumcision2,3.

What has happened in the last seven years to make circumcision less controversial? Why does the NEJM only present the purported benefits of circumcision? Why did the NEJM fail to print any letters critical of this pro-circumcision agenda? Let's recap some of the research that they overlooked.

Circumcision is losing popularity in the United States and has been discredited by the Canadian Pediatric Society4 and the Australasian Pediatric Surgeons5 in 1996 position papers. Taylor described the unique innervation of the preputial mucosa in 1996, and its loss to circumcision6. Taddio et al. showed that circumcision with and without local anesthesia (EMLA) resulted in negative behavioral changes in a child's' response to pain7. Laumann has shown that circumcision causes sexual behavior changes and an apparent increased risk of many venereal diseases in adult men8. Price has questioned whether parents can ethically change their child's genitalia9. The editorial staff at NEJM could not have missed these advances. So why did they not present another Sounding Board article, and instead choose to present only a pro-circumcision editorial by Wiswell?

In a previous article in the NEJM, Royce et al. insinuated that the prepuce may be a risk factor for HIV infections.10 This factually inaccurate article was referenced in a letter to the editor as proof that circumcision protects an individual from HIV infections.11 Fortunately, Laumann pointed out the fallacy of this logic. "The lack of rigorous, systematic controls for co-factors relevant to the particularities of the African context, the prophylactic status of the presence or absence of the foreskin remains an open question12." But the fact that the NEJM failed to print our letter of criticism (see Abstracts & Analysis), suggests that the NEJM only prints material that supports neonatal circumcision.

Beyond Wiswell's proclamation of the benefits of circumcision, the research presented by Taddio et al.13 was proclaimed as a major advance. When the limitations of this form of local anesthesia was brought to the attention of the editors, they failed to print the criticism (see Abstracts & Analysis). They failed to point out that this form of local anesthesia (EMLA) did not prevent the long term negative behavioral response to pain previously reported in the Lancet7!

Interestingly, the lack of effects of EMLA on long term negative behavioral changes caused by circumcision was printed in a British medical journal. Presumably, Taddio is smart enough to submit negative studies to European medical journals7,14 and luke-warm studies to American medical journals13.

Certainly, over the last seven years, the NEJM has shifted from a balanced approach, to a one-sided, pro-circumcision stance, even though the lion's share of the medical literature would encourage a shift in the opposite direction. It is hoped that in the near future, the NEJM will have the courage to confront the ethical problems and medical complications associated with circumcision. Maybe then, it will be acceptable for a physician to tell the parents of a newborn child, "Your baby has normal anatomy, so there is no need to charge you money to surgically alter this child's genital anatomy. If your son or daughter wants to change their genital anatomy, they are free to do so after age 18, when they can make an informed decision." Physicians will then be able to teach parents not to fear normal anatomy.

Normal anatomy is not as dirty and dangerous as once thought. Even if a part of the body is malformed, diseased, or carries some risk, an individual must retain the right to refuse surgery. Prophylactic removal of normal anatomy to please parents, or to produce income for the physician is unethical. I hope the NEJM can temper its pro-circumcision agenda. Circumcision of medical knowledge and information is more dangerous than amputating part of the penis from a restrained, non-consenting baby.

Christopher J. Cold, MD
Department of Pathology
Marshfield Clinic

References

  1. Wiswell TE. Circumcision circumspection. N Engl J Med 1997; 336:1244-5.
  2. Schoen EJ. The status of circumcision of newborns. N Engl J Med 1990; 322:1308-12.
  3. Poland RL. The question of routine neonatal circumcision. N Engl J Med. 1990; 322:1312-5.
  4. Fetus and Newborn Committee, Canadian Paediatric Society. Neonatal circumcision revisited. Can Med Assoc J 1996; 154:769-80.
  5. Australasian Association of Paediatric Surgeons. Guidelines for circumcision. April 1996.
  6. Taylor JR, Lockwood AP, Taylor AJ. The prepuce: specialized mucosa of the penis and its loss to circumcision. Br J Urol 1996; 77:291-95.
  7. Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997; 349:599-603.
  8. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United States: prevalence, prophylactic effects, and sexual practices, and sexual practice. JAMA 1997; 277:1052-7.
  9. Price (Bull. Medical Ethics).
  10. Royce RA, Sena A, Cates W Jr, Cohen MS. Sexual transmission of HIV. N Engl J M ed 1997; 336:1072-1078.
  11. JAMA 1997; 278(3):201
  12. Laumann EO. JAMA 1997; 278(3):203
  13. Taddio A, Stevens B, Craig K, Rastogi P, Ben-David S, Shennan A, Mulligan P, Koren G. Efficacy and safety of lidocaine-prilocaine cream for pain during circumcision. N Engl J Med 1997; 336:1197-1201.
  14. Taddio A, Goldbach M, Ipp M, Stevens B, Koren G Effect of neonatal circumcision on pain responses during vaccination in boys. Lancet 1995; 345:291-2.

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